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92_SB0034
LRB9202541DJgc
1 AN ACT concerning public aid.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Illinois Public Aid Code is amended by
5 changing Section 5-5 as follows:
6 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
7 Sec. 5-5. Medical services. The Illinois Department, by
8 rule, shall determine the quantity and quality of and the
9 rate of reimbursement for the medical assistance for which
10 payment will be authorized, and the medical services to be
11 provided, which may include all or part of the following: (1)
12 inpatient hospital services; (2) outpatient hospital
13 services; (3) other laboratory and X-ray services; (4)
14 skilled nursing home services; (5) physicians' services
15 whether furnished in the office, the patient's home, a
16 hospital, a skilled nursing home, or elsewhere; (6) medical
17 care, or any other type of remedial care furnished by
18 licensed practitioners; (7) home health care services; (8)
19 private duty nursing service; (9) clinic services; (10)
20 dental services including, without limitation, the following:
21 periodontal scaling (American Medical Association current
22 procedural terminology (CPT) Code 04341), periodontal
23 maintenance (CPT Code 04910), patient instruction (CPT Code
24 01340), adult prophylaxis (CPT Code D1110), adult fluoride
25 (CPT Code D1204), and partial dentures (CPT Codes D5211,
26 D5212, D5213, D5214, and D5281); (11) physical therapy and
27 related services; (12) prescribed drugs, dentures, and
28 prosthetic devices; and eyeglasses prescribed by a physician
29 skilled in the diseases of the eye, or by an optometrist,
30 whichever the person may select; (13) other diagnostic,
31 screening, preventive, and rehabilitative services; (14)
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1 transportation and such other expenses as may be necessary;
2 (15) medical treatment of sexual assault survivors, as
3 defined in Section 1a of the Sexual Assault Survivors
4 Emergency Treatment Act, for injuries sustained as a result
5 of the sexual assault, including examinations and laboratory
6 tests to discover evidence which may be used in criminal
7 proceedings arising from the sexual assault; (16) the
8 diagnosis and treatment of sickle cell anemia; and (17) any
9 other medical care, and any other type of remedial care
10 recognized under the laws of this State, but not including
11 abortions, or induced miscarriages or premature births,
12 unless, in the opinion of a physician, such procedures are
13 necessary for the preservation of the life of the woman
14 seeking such treatment, or except an induced premature birth
15 intended to produce a live viable child and such procedure is
16 necessary for the health of the mother or her unborn child.
17 The Illinois Department, by rule, shall prohibit any
18 physician from providing medical assistance to anyone
19 eligible therefor under this Code where such physician has
20 been found guilty of performing an abortion procedure in a
21 wilful and wanton manner upon a woman who was not pregnant at
22 the time such abortion procedure was performed. The term "any
23 other type of remedial care" shall include nursing care and
24 nursing home service for persons who rely on treatment by
25 spiritual means alone through prayer for healing.
26 Notwithstanding any other provision of this Section, a
27 comprehensive tobacco use cessation program that includes
28 purchasing prescription drugs or prescription medical devices
29 approved by the Food and Drug administration shall be covered
30 under the medical assistance program under this Article for
31 persons who are otherwise eligible for assistance under this
32 Article.
33 Notwithstanding any other provision of this Code, the
34 Illinois Department may not require, as a condition of
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1 payment for any laboratory test authorized under this
2 Article, that a physician's handwritten signature appear on
3 the laboratory test order form. The Illinois Department may,
4 however, impose other appropriate requirements regarding
5 laboratory test order documentation.
6 The Illinois Department of Public Aid shall provide the
7 following services to persons eligible for assistance under
8 this Article who are participating in education, training or
9 employment programs operated by the Department of Human
10 Services as successor to the Department of Public Aid:
11 (1) dental services, which shall include but not be
12 limited to prosthodontics and the following: periodontal
13 scaling (American Medical Association current procedural
14 terminology (CPT) Code 04341), periodontal maintenance
15 (CPT Code 04910), patient instruction (CPT Code 01340),
16 adult prophylaxis (CPT Code D1110), adult fluoride (CPT
17 Code D1204), and partial dentures (CPT Codes D5211,
18 D5212, D5213, D5214, and D5281); and
19 (2) eyeglasses prescribed by a physician skilled in
20 the diseases of the eye, or by an optometrist, whichever
21 the person may select.
22 The Illinois Department, by rule, may distinguish and
23 classify the medical services to be provided only in
24 accordance with the classes of persons designated in Section
25 5-2.
26 The Illinois Department shall authorize the provision of,
27 and shall authorize payment for, screening by low-dose
28 mammography for the presence of occult breast cancer for
29 women 35 years of age or older who are eligible for medical
30 assistance under this Article, as follows: a baseline
31 mammogram for women 35 to 39 years of age and an annual
32 mammogram for women 40 years of age or older. All screenings
33 shall include a physical breast exam, instruction on
34 self-examination and information regarding the frequency of
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1 self-examination and its value as a preventative tool. As
2 used in this Section, "low-dose mammography" means the x-ray
3 examination of the breast using equipment dedicated
4 specifically for mammography, including the x-ray tube,
5 filter, compression device, image receptor, and cassettes,
6 with an average radiation exposure delivery of less than one
7 rad mid-breast, with 2 views for each breast.
8 Any medical or health care provider shall immediately
9 recommend, to any pregnant woman who is being provided
10 prenatal services and is suspected of drug abuse or is
11 addicted as defined in the Alcoholism and Other Drug Abuse
12 and Dependency Act, referral to a local substance abuse
13 treatment provider licensed by the Department of Human
14 Services or to a licensed hospital which provides substance
15 abuse treatment services. The Department of Public Aid shall
16 assure coverage for the cost of treatment of the drug abuse
17 or addiction for pregnant recipients in accordance with the
18 Illinois Medicaid Program in conjunction with the Department
19 of Human Services.
20 All medical providers providing medical assistance to
21 pregnant women under this Code shall receive information from
22 the Department on the availability of services under the Drug
23 Free Families with a Future or any comparable program
24 providing case management services for addicted women,
25 including information on appropriate referrals for other
26 social services that may be needed by addicted women in
27 addition to treatment for addiction.
28 The Illinois Department, in cooperation with the
29 Departments of Human Services (as successor to the Department
30 of Alcoholism and Substance Abuse) and Public Health, through
31 a public awareness campaign, may provide information
32 concerning treatment for alcoholism and drug abuse and
33 addiction, prenatal health care, and other pertinent programs
34 directed at reducing the number of drug-affected infants born
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1 to recipients of medical assistance.
2 Neither the Illinois Department of Public Aid nor the
3 Department of Human Services shall sanction the recipient
4 solely on the basis of her substance abuse.
5 The Illinois Department shall establish such regulations
6 governing the dispensing of health services under this
7 Article as it shall deem appropriate. In formulating these
8 regulations the Illinois Department shall consult with and
9 give substantial weight to the recommendations offered by the
10 Citizens Assembly/Council on Public Aid. The Department
11 should seek the advice of formal professional advisory
12 committees appointed by the Director of the Illinois
13 Department for the purpose of providing regular advice on
14 policy and administrative matters, information dissemination
15 and educational activities for medical and health care
16 providers, and consistency in procedures to the Illinois
17 Department.
18 The Illinois Department may develop and contract with
19 Partnerships of medical providers to arrange medical services
20 for persons eligible under Section 5-2 of this Code.
21 Implementation of this Section may be by demonstration
22 projects in certain geographic areas. The Partnership shall
23 be represented by a sponsor organization. The Department, by
24 rule, shall develop qualifications for sponsors of
25 Partnerships. Nothing in this Section shall be construed to
26 require that the sponsor organization be a medical
27 organization.
28 The sponsor must negotiate formal written contracts with
29 medical providers for physician services, inpatient and
30 outpatient hospital care, home health services, treatment for
31 alcoholism and substance abuse, and other services determined
32 necessary by the Illinois Department by rule for delivery by
33 Partnerships. Physician services must include prenatal and
34 obstetrical care. The Illinois Department shall reimburse
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1 medical services delivered by Partnership providers to
2 clients in target areas according to provisions of this
3 Article and the Illinois Health Finance Reform Act, except
4 that:
5 (1) Physicians participating in a Partnership and
6 providing certain services, which shall be determined by
7 the Illinois Department, to persons in areas covered by
8 the Partnership may receive an additional surcharge for
9 such services.
10 (2) The Department may elect to consider and
11 negotiate financial incentives to encourage the
12 development of Partnerships and the efficient delivery of
13 medical care.
14 (3) Persons receiving medical services through
15 Partnerships may receive medical and case management
16 services above the level usually offered through the
17 medical assistance program.
18 Medical providers shall be required to meet certain
19 qualifications to participate in Partnerships to ensure the
20 delivery of high quality medical services. These
21 qualifications shall be determined by rule of the Illinois
22 Department and may be higher than qualifications for
23 participation in the medical assistance program. Partnership
24 sponsors may prescribe reasonable additional qualifications
25 for participation by medical providers, only with the prior
26 written approval of the Illinois Department.
27 Nothing in this Section shall limit the free choice of
28 practitioners, hospitals, and other providers of medical
29 services by clients. In order to ensure patient freedom of
30 choice, the Illinois Department shall immediately promulgate
31 all rules and take all other necessary actions so that
32 provided services may be accessed from therapeutically
33 certified optometrists to the full extent of the Illinois
34 Optometric Practice Act of 1987 without discriminating
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1 between service providers.
2 The Department shall apply for a waiver from the United
3 States Health Care Financing Administration to allow for the
4 implementation of Partnerships under this Section.
5 The Illinois Department shall require health care
6 providers to maintain records that document the medical care
7 and services provided to recipients of Medical Assistance
8 under this Article. The Illinois Department shall require
9 health care providers to make available, when authorized by
10 the patient, in writing, the medical records in a timely
11 fashion to other health care providers who are treating or
12 serving persons eligible for Medical Assistance under this
13 Article. All dispensers of medical services shall be
14 required to maintain and retain business and professional
15 records sufficient to fully and accurately document the
16 nature, scope, details and receipt of the health care
17 provided to persons eligible for medical assistance under
18 this Code, in accordance with regulations promulgated by the
19 Illinois Department. The rules and regulations shall require
20 that proof of the receipt of prescription drugs, dentures,
21 prosthetic devices and eyeglasses by eligible persons under
22 this Section accompany each claim for reimbursement submitted
23 by the dispenser of such medical services. No such claims for
24 reimbursement shall be approved for payment by the Illinois
25 Department without such proof of receipt, unless the Illinois
26 Department shall have put into effect and shall be operating
27 a system of post-payment audit and review which shall, on a
28 sampling basis, be deemed adequate by the Illinois Department
29 to assure that such drugs, dentures, prosthetic devices and
30 eyeglasses for which payment is being made are actually being
31 received by eligible recipients. Within 90 days after the
32 effective date of this amendatory Act of 1984, the Illinois
33 Department shall establish a current list of acquisition
34 costs for all prosthetic devices and any other items
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1 recognized as medical equipment and supplies reimbursable
2 under this Article and shall update such list on a quarterly
3 basis, except that the acquisition costs of all prescription
4 drugs shall be updated no less frequently than every 30 days
5 as required by Section 5-5.12.
6 The rules and regulations of the Illinois Department
7 shall require that a written statement including the required
8 opinion of a physician shall accompany any claim for
9 reimbursement for abortions, or induced miscarriages or
10 premature births. This statement shall indicate what
11 procedures were used in providing such medical services.
12 The Illinois Department shall require that all dispensers
13 of medical services, other than an individual practitioner or
14 group of practitioners, desiring to participate in the
15 Medical Assistance program established under this Article to
16 disclose all financial, beneficial, ownership, equity, surety
17 or other interests in any and all firms, corporations,
18 partnerships, associations, business enterprises, joint
19 ventures, agencies, institutions or other legal entities
20 providing any form of health care services in this State
21 under this Article.
22 The Illinois Department may require that all dispensers
23 of medical services desiring to participate in the medical
24 assistance program established under this Article disclose,
25 under such terms and conditions as the Illinois Department
26 may by rule establish, all inquiries from clients and
27 attorneys regarding medical bills paid by the Illinois
28 Department, which inquiries could indicate potential
29 existence of claims or liens for the Illinois Department.
30 The Illinois Department shall establish policies,
31 procedures, standards and criteria by rule for the
32 acquisition, repair and replacement of orthotic and
33 prosthetic devices and durable medical equipment. Such rules
34 shall provide, but not be limited to, the following services:
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1 (1) immediate repair or replacement of such devices by
2 recipients without medical authorization; and (2) rental,
3 lease, purchase or lease-purchase of durable medical
4 equipment in a cost-effective manner, taking into
5 consideration the recipient's medical prognosis, the extent
6 of the recipient's needs, and the requirements and costs for
7 maintaining such equipment. Such rules shall enable a
8 recipient to temporarily acquire and use alternative or
9 substitute devices or equipment pending repairs or
10 replacements of any device or equipment previously authorized
11 for such recipient by the Department. Rules under clause (2)
12 above shall not provide for purchase or lease-purchase of
13 durable medical equipment or supplies used for the purpose of
14 oxygen delivery and respiratory care.
15 The Department shall execute, relative to the nursing
16 home prescreening project, written inter-agency agreements
17 with the Department of Human Services and the Department on
18 Aging, to effect the following: (i) intake procedures and
19 common eligibility criteria for those persons who are
20 receiving non-institutional services; and (ii) the
21 establishment and development of non-institutional services
22 in areas of the State where they are not currently available
23 or are undeveloped.
24 The Illinois Department shall develop and operate, in
25 cooperation with other State Departments and agencies and in
26 compliance with applicable federal laws and regulations,
27 appropriate and effective systems of health care evaluation
28 and programs for monitoring of utilization of health care
29 services and facilities, as it affects persons eligible for
30 medical assistance under this Code. The Illinois Department
31 shall report regularly the results of the operation of such
32 systems and programs to the Citizens Assembly/Council on
33 Public Aid to enable the Committee to ensure, from time to
34 time, that these programs are effective and meaningful.
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1 The Illinois Department shall report annually to the
2 General Assembly, no later than the second Friday in April of
3 1979 and each year thereafter, in regard to:
4 (a) actual statistics and trends in utilization of
5 medical services by public aid recipients;
6 (b) actual statistics and trends in the provision
7 of the various medical services by medical vendors;
8 (c) current rate structures and proposed changes in
9 those rate structures for the various medical vendors;
10 and
11 (d) efforts at utilization review and control by
12 the Illinois Department.
13 The period covered by each report shall be the 3 years
14 ending on the June 30 prior to the report. The report shall
15 include suggested legislation for consideration by the
16 General Assembly. The filing of one copy of the report with
17 the Speaker, one copy with the Minority Leader and one copy
18 with the Clerk of the House of Representatives, one copy with
19 the President, one copy with the Minority Leader and one copy
20 with the Secretary of the Senate, one copy with the
21 Legislative Research Unit, such additional copies with the
22 State Government Report Distribution Center for the General
23 Assembly as is required under paragraph (t) of Section 7 of
24 the State Library Act and one copy with the Citizens
25 Assembly/Council on Public Aid or its successor shall be
26 deemed sufficient to comply with this Section.
27 (Source: P.A. 90-7, eff. 6-10-97; 90-14, eff. 7-1-97; 91-344,
28 eff. 1-1-00; 91-462, eff. 8-6-99; 91-666, eff. 12-22-99;
29 revised 1-6-00.)
30 Section 99. Effective date. This Act takes effect on
31 July 1, 2001.